Provider Demographics
NPI:1366031593
Name:STOUT, DAVID (PTA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:STOUT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3223 E 31ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-2452
Mailing Address - Country:US
Mailing Address - Phone:918-250-7093
Mailing Address - Fax:918-250-9976
Practice Address - Street 1:3223 E 31ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-2452
Practice Address - Country:US
Practice Address - Phone:918-250-7093
Practice Address - Fax:918-250-9976
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3201225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant